2. Aims
• Cover common presentations
• Case based scenarios
• SOCRATES
• "In a surgeon's gown
physicians may make some
clinical progress"
• General rules for MSK
examination
• Detailed guides for specific
examination
3. Case 1
• A 63 year old male farmer presents to you their GP, with
increasing stiffness and pain in his hands. The patient
has only been seen once previously, takes no regular
medication and has no recorded medical history.
• Please take a focused history and examination.
4. Case 1
• Pain - SOCRATES
• Ache, worse over day, all
fingers symmetrically,
worse in thumb bases,
paracetamol works but
doesn't want to get
addicted
• Family history
• Aches and pains when
old
• Previous similar episodes
• On and off ache but no
clear episodes
• Other joints
• Knees aren't great but
not the main issue
• Other illness or symptoms
• Fit as a fiddle, no trauma
5. Case 1
• Tough hard skin on
palms
• Nails dirty and chipped
• No temp difference
• Hard nodules on DIPJ
• 1st MCPJ "squared off"
• ROM equal bilateral
• Grip strength
maintained
• Normal sensation
7. Case 1
• Osteoarthritis
• Heberden's nodes vs
Bouchard's nodes
• Investigation
• Blood tests
• Imaging
• Aspiration
• Causes
• Primary - idiopathic
• Secondary - trauma,
infection, obesity
• Management
• Life style - work and weight
• Medication - analgesia and
disease modifying
• Surgery
8. Case 2
• You are on placement in a general practice. A 26 year
old male presents with recurrent neck pain and stiffness.
The system shows they have been seen multiple times
for this complaint and have some other chronic
conditions.
• Please perform a focused history and examination.
9. Case 2
• Pain - SOCRATES
• Stiffness more than pain,
worse some days, no clear
pattern, analgesia helps
with pain
• Family history
• Remembers Gran on
fathers side was known as
"the hunchback"
• Previous similar episodes
• Multiple episodes all
attributed to active lifestyle
or injury
• Other joints
• Neck and back
predominantly
• Other illness or symptoms
• Occasional asthma but
under control with inhalers
10. Case 2
• No skin changes
• No gross deformity of
spine
• Normal palpation of
entire spine
• Markedly reduced ROM
in cervical spine in all
planes
• FROM rest of spine
• Neurologically normal
12. Case 2
• Ankylosing spondylitis
• "Bamboo spine"
• Investigations
• Blood test
• Imaging
• Management
• Life style - work and
weight
• Medication - analgesia
and disease modifying
• Surgery
13. Case 3
• You are on placement in a general practice. A 51 year
old female patient has come in to discuss aches and
pains in her hands and feet. She has been seen most
recently about dry eyes.
• Please perform a focused history and examination.
14. Case 3
• Pain - SOCRATES
• Stiffness associated with pain,
worse in episodes that last days,
seems to improve with
movement and eventually settles
for a while, analgesia helps with
pain toward the end of these
attacks
• Family history
• All parents have had aches when
older, but mother may have had
them in her 40's, ended up with
"odd looking fingers"
• Previous similar episodes
• Multiple episodes self resolved
but seem to be getting longer
and more deformity esp in fingers
• Other joints
• Fingers and feet cause majority
of pain
• Other illness or symptoms
• Dry eyes - recently given eye
drops
15. Case 3
• No skin changes
• Nails dry and cracked
• No temp difference
• Boggy swelling of all
small joints of hands
• Deformity of joints
• Reduced extension in
fingers
• Grip strength reduced
bilaterally
• Normal sensation
17. Case 3
• Rheumatoid arthritis
• Ulnar deviation and swan
neck deformity
• Investigations
• Blood test
• Imaging
• Management
• Life style - work and
weight
• Medication - analgesia
and disease modifying
• Surgery
18. Case 4
• You are on placement in a general practice. A 41 year
old handy man is booked in to see you about a pain in
his left shoulder.
• Please perform a focused history and examination.
19. Case 4
• Pain - SOCRATES
• Sudden onset, day after
a big job repainting a
house, generalised
around shoulder and
upper arm, unable to
sleep in this side
• Family history
• Nil
• Previous similar episodes
• Less severe episode 2
weeks ago, settled with
simple analgesia
• Other joints
• No other problems
• Other illness or symptoms
• Nil
20. Case 4
• No skin changes
• No temp difference
• Shoulders and muscle
bulk appear symmetrical
• Unable to actively abduct
the shoulder due to pain
• Passive movement is
normal however is
painful
• No winging of the
scapula
• Apprehension test
positive
22. Case 4
• Rotator cuff lesion
• Investigations
• Blood test
• Imaging
• Management
• Life style - work and
weight
• Medication - analgesia
and disease modifying
• Surgery
23. Generic MSK Examination
• Wash hands
• Clarify your ID
• Explain what you are going to
do
• Gain consent
• Exposure - even if patient is in
shorts as examiner will inform
you if not necessary
• Compare both sides
• Look, feel, move +/- special
tests
• Neurovascular status
• Cover or suggest to redress.
• Wash hands
• Thank patient
• Suggest further beside tests
and investigations
24. Ankle and Foot Examination
• Common presentation
• ED, GP, Ortho/Rheum clinic
• Acute and chronic
• Fractures, plantar fasciitis, tendinitis
• Degenerative and inflammatory arthritis
• Ask patient to walk to assess gait
• Standing
• Varus/Valgus, arches, Achilles' tendon
• Inspect shoes
• Ask patient to get on bed
• Inspect
• Symmetry, nails, skin, toes, calluses
• Palpate
• Temperature
• Joints - begin proximal, IPJ - MTPJ - mid
foot - subtalar joint - ankle
• Pulses
• Movement
• Inversion, eversion, dorsiflexion,
plantarflexion
• Not forgetting mid foot inversion and
eversion
25. Knee Examination
• Common presentation
• ED, GP, Ortho/Rheum clinic
• Acute and chronic
• Pain, locking or giving way
• Fractures, bursitis, ligamental or cartilage damage
• Degenerative and inflammatory arthritis
• Ask patient to walk
• Gait and muscle bulk
• Standing
• Varus/Valgus, symmetry, hyperextension, bakers cyst
• Inspect shoes
• Ask patient to get on bed
• Inspect
• Symmetry and effusion
• Palpate
• Temperature
• With knee flexed to 90 degrees - joint line, patella tendon
• Gutter sweep and patella tap
• Pulses
• Movement
• Flexion and extension
• Special
• Anterior Draw's test - knee flexed at 90 degrees, foot fixed by
sitting on (inform patient), thumbs on joint line, fingers behind
tibia, if no end point likely ACL rupture
• Posterior sag (Pen Test) - observe knee from side, place pen
on tibial tuberosity, if PCL is ruptured the tibia will shift
posteriorly no gap between pen, if gap half way but touching
top and bottom (severe shift), if gap at top of pen normal.
• Lateral and medial stress test - hold ankle in axial, knee flexed
to 15 degree, stress medial and lateral colaterals, if excessive
movement compare to unaffected side.
• McMurray's test - DO NOT PREFORM!
26. Hip Examination
• Common presentation
• ED, GP, Ortho/Rheum clinic
• Acute and chronic
• Fractures, bursitis, irritable hip, perches disease,
slipped upper femoral epiphysis.
• Degenerative and inflammatory arthritis
• Referred pain - esp knee and spine
• Ask patient to walk
• Gait (antalgic or trendelenburg), muscle bulk
• Standing
• Varus/Valgus, pelvic tilt, spine
• Inspect shoes
• Ask patient to get on bed
• Inspect
• Symmetry, apparent and true leg length
• Palpate
• Temperature
• Joint, muscle bulk and over bursa
• Pulses
• Movement
• Flexion, extension, internal and external rotation
• Special
• Thomas' test - hand under lumbar spine, flex
opposite hip, if hip lifts off hand this confirms a
fixed flexion deformity
27. Spine Examination
• Common presentation
• ED, GP, Ortho/Rheum clinic
• Acute and chronic
• Fractures, discitis, spondyloarthropathy
• Degenerative and inflammatory arthritis
• Ask patient to walk
• Standing
• Scoliosis, cervical lordosis, thoracic
kyphosis, lumbar lordosis and muscle bulk
• Inspect shoes
• Ask patient to get on bed
• Sat facing away from you or sideways on a
chair
• Palpate
• Start head to toe along spinous processes,
sacroiliac joints, paraspinal muscles
• Movement - active only
• Lumbar flexion, extension and lateral flexion
• Thoracic rotation - fix pelvis by sitting patient
down
• Special
• Straight leg raise - diagnostic of sciatica
• Neurological exam a must - be guided by
sight of pain
28. Shoulder Examination
• Common presentation
• ED, GP, Ortho/Rheum clinic
• Acute and chronic
• Fractures, bursitis, frozen shoulder, painful arch,
rotator cuff, impingement
• Degenerative and inflammatory arthritis
• Referred pain - esp spine
• Standing - Inspect
• Muscle bulk, symmetry and natural stance
• Ask patient to get on bed
• Sat up facing away from you or sideways on a chair
• Palpate
• Temperature
• Sternoclavicular joint - clavicle - acromioclavicular joint -
acromion - spine of scapula - anterior then posterior
glenohumeral joint - muscle bulk around shoulder
• Pulses
• Movement
• Flexion, extension, abduction, adduction internal and
external rotation
• Special
• Impingement test - hold shoulder at 90 degrees with the
forearm pointing down, press backward on arm,
positive if pain
• Apprehension test - hold shoulder at 90 degrees with
the forearm pointing upward, press backward on arm,
positive if patient feels instability
• Scarf test - hold elbow at 90 degrees, inform patient to
place hand on other shoulder and push back.
• Functional test - hands behind head, hands behind
lumbar spine
29. Elbow Examination
• Common presentation
• ED, GP, Ortho/Rheum clinic
• Acute and chronic
• Fractures, epicondylitis, bursitis, ulnar nerve
entrapment
• Degenerative and inflammatory arthritis
• Ask patient to stand in comfortable position
• Standing
• Normal "carrying stance"
• Inspect
• Symmetry, skin
• Palpate
• Temperature
• Olecranon, lateral and medial epicondyle
• Pulses
• Movement
• Flexion, extension, pronation, supination
• Special
• Tennis elbow - active extension wrist with
elbow bent will localise to lateral epicondyle
• Golfer's elbow - active wrist flexion with
elbow bent will localise to medial epicondyle
30. Hand and Wrist Examination
• Common presentation
• ED, GP, Ortho/Rheum clinic
• Acute and chronic
• Fractures, tendinitis, trigger finger, Dupuytren's disease
• Carpal tunnel, ganglion
• Degenerative and inflammatory arthritis
• Most commonly examined are OA, RA and psoriatic
arthritis
• Swan neck deformity, Bouchard's nodes, Heberden's nodes
• Place hands on pillow or table between you and patient
• Inspect
• Symmetry, nails, skin, fingers, cascade
• Palpate
• Temperature
• Joints - begin distal, IPJ - MCPJ - MCCJ - Carpal rows -
wrist
• Thenar and hypothenar
• Tendon thickening
• Pulses and sensation
• Movement
• Wrist flexion and extension
• Finger flexion, extension, abduction and adduction
• Thumb abduction and opposition
• Grip
• Special
• Phalen's test - diagnostic of carpal tunnel, forced and held
flexion for 60 seconds
• Froment's test - ulnar nerve function test, hold piece of
paper between straight thumb and index finger, testing
adductor pollicus, if patient has palsy will flex to
compensate
